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Article

Admission Liver Enzyme Elevation Grade for Risk Stratification in Critically Ill Patients: Development and Internal Validation of an Exploratory Prognostic Model

by
Giovanni Giordano
1,
Veronica Zullino
2,
Antonella Tosi
2,
Giacomo Monaco
2,
Beatrice Frasacco
1,*,
Paola Celli
2,
Franco Ruberto
1,
Pierfrancesco Tozzi
2,
Francesco Alessandri
1 and
Francesco Pugliese
1
1
Department of General and Specialistic Surgery and Anesthesiology, “Sapienza” University of Rome, 00185 Rome, Italy
2
Department of Emergency Care, Critical Care and Trauma, Policlinico Umberto I Hospital, 00161 Rome, Italy
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2026, 15(14), 5513; https://doi.org/10.3390/jcm15145513
Submission received: 8 June 2026 / Revised: 10 July 2026 / Accepted: 13 July 2026 / Published: 14 July 2026
(This article belongs to the Special Issue New Perspectives and Innovations in Critical Illness)
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Abstract

Background: Liver enzyme abnormalities are common in critically ill patients, but the prognostic relevance of graded aminotransferase elevation and its timing remains uncertain. We evaluated whether Liver Enzyme Elevation (LEE) grade at ICU admission provides prognostic information beyond SAPS II in a heterogeneous ICU cohort. Methods: In this single-centre retrospective study, adult patients admitted to a mixed ICU between January 2023 and December 2024 and with ICU length of stay ≥72 h were analysed. LEE grade was assigned from AST and ALT according to predefined multiples of the local upper limit of normal, using the higher grade reached by either enzyme. The primary outcome was ICU mortality. Secondary outcomes included renal replacement therapy, ICU length of stay, and duration of invasive mechanical ventilation. A fixed logistic model including SAPS II and admission LEE grade was internally validated by bootstrap resampling. Results: Among 274 patients, ICU mortality was 27.7%. Admission LEE grade showed an adjusted association with ICU mortality (OR 1.26 per grade increase, 95% CI 1.00–1.58; p = 0.048), while SAPS II remained the dominant predictor (OR 1.04 per point, 95% CI 1.02–1.06; p < 0.001). Adding admission LEE grade to SAPS II yielded a small absolute increase in discrimination (AUC 0.737 vs. 0.703; DeLong p = 0.039). Bootstrap-corrected AUC was 0.730, with acceptable overall calibration. Admission LEE grade was also associated with RRT and longer ICU stay in exploratory secondary analyses. Conclusions: Admission LEE grade may provide modest complementary prognostic information beyond SAPS II. These findings are exploratory and require external validation before clinical implementation.
Keywords: liver enzyme elevation; critical illness; ICU mortality; risk stratification; transaminases liver enzyme elevation; critical illness; ICU mortality; risk stratification; transaminases

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MDPI and ACS Style

Giordano, G.; Zullino, V.; Tosi, A.; Monaco, G.; Frasacco, B.; Celli, P.; Ruberto, F.; Tozzi, P.; Alessandri, F.; Pugliese, F. Admission Liver Enzyme Elevation Grade for Risk Stratification in Critically Ill Patients: Development and Internal Validation of an Exploratory Prognostic Model. J. Clin. Med. 2026, 15, 5513. https://doi.org/10.3390/jcm15145513

AMA Style

Giordano G, Zullino V, Tosi A, Monaco G, Frasacco B, Celli P, Ruberto F, Tozzi P, Alessandri F, Pugliese F. Admission Liver Enzyme Elevation Grade for Risk Stratification in Critically Ill Patients: Development and Internal Validation of an Exploratory Prognostic Model. Journal of Clinical Medicine. 2026; 15(14):5513. https://doi.org/10.3390/jcm15145513

Chicago/Turabian Style

Giordano, Giovanni, Veronica Zullino, Antonella Tosi, Giacomo Monaco, Beatrice Frasacco, Paola Celli, Franco Ruberto, Pierfrancesco Tozzi, Francesco Alessandri, and Francesco Pugliese. 2026. "Admission Liver Enzyme Elevation Grade for Risk Stratification in Critically Ill Patients: Development and Internal Validation of an Exploratory Prognostic Model" Journal of Clinical Medicine 15, no. 14: 5513. https://doi.org/10.3390/jcm15145513

APA Style

Giordano, G., Zullino, V., Tosi, A., Monaco, G., Frasacco, B., Celli, P., Ruberto, F., Tozzi, P., Alessandri, F., & Pugliese, F. (2026). Admission Liver Enzyme Elevation Grade for Risk Stratification in Critically Ill Patients: Development and Internal Validation of an Exploratory Prognostic Model. Journal of Clinical Medicine, 15(14), 5513. https://doi.org/10.3390/jcm15145513

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